Medical reports on torture victims in the state's care are of poor quality and lack clinical judgement, says HM Inspectorate of Prisons
Last week’s HM Inspector of Prisons report on Harmondsworth Removal Centre contains this shocking observation about so-called ‘Rule 35’ medical reports “relating to detainees who had experienced torture or were unfit to detain.” They “were of poor quality, often providing no clinical judgement.”
Rule 35 of the Detention Centre Rules (a statutory instrument) requires doctors working in detention centres to inform the detaining authority of persons about whom they have concerns that they may have been victims of torture before entering the UK. On receipt of such evidence, the responsible official is required to consider this information and release the person.
As a doctor I have examined at least 400 people during or
after detention who say they were tortured in places such as Zimbabwe, Sri
Lanka, or Iran before fleeing to the UK to request asylum. The vast majority
displayed scars from cigarette burns or branding with hot irons, evidence of
severe beatings, electrocution, stabbing or gun shot wounds. Most had blatant
post-traumatic stress disorder and/or depression that was exacerbated or
re-ignited by detention. While examining them, I have had occasion to read
their rule 35 reports and detention medical notes. They
confirm HMIP’s findings that these reports were generally “of poor
quality, often providing no clinical judgement.”
Approximately 26,000 asylum seekers and other migrants are subjected to administrative detention in one of 11 “removal centres” in the UK each year. It is law and policy that those among them (possibly numbering thousands) who are torture survivors, people with serious illnesses and pregnant women should be detained “only under very exceptional circumstances.” Sadly, in pursuit of their targets to remove more “illegal immigrants” than enter the UK each year, the UK Border Agency, routinely, expensively and harmfully violate these principles.
In 2010, the government paid out about £4 million in compensation for wrongful detention and other unlawful acts against asylum seekers. This figure is a gross under-estimate. It fails to account for the legal expenses (roughly £10 million) and for the costs of inappropriate detention itself (perhaps £2 million). Aside from the waste of public funds, the victims, mostly survivors of torture, are often seriously damaged as a result of their incarceration. By the time that many are finally released and determined to have a “well founded fear” of further abuse if returned to their countries of origin – which can take years – they are often seriously re-traumatised and in need of extensive and expensive therapy.
To prevent these undesirable outcomes, Parliament insisted on Detention Centre Rules, including the crucial number 35 (see below) which is supposed to protect torture victims from inappropriate incarceration. Unfortunately – as is so often the case – a benign policy is betrayed by deplorable practice, as the Prisons Inspectorate about Harmondsworth (and many previous ones about immigration detention) make clear.
In only three of the more than 400 cases I have seen did a doctor trouble to describe adequately their clinical findings and draw reasoned conclusions based on the international medico-legal standard, the Istanbul Protocol on the documentation of torture. Most reports were written by nurses or administrative assistants, not doctors. This is also in violation of the Rules. Some claimed that the person was “not tortured” despite readily visible cigarette or taser burns. Other Rule 35 reports gave a word-for-word transcript of the patient's description of their physical abuse, but negligently showed no evidence of any examination whatever.
On those occasions where the report was adequate the response from the detaining authority was usually formulaic: it was held not to be “independent evidence” of torture. This reply is intriguing: are UKBA saying that doctors working for them under subcontract are not “independent”, or not sufficiently competent that the products of their examinations may be called “evidence”?
The Inspectorate report mentions that UKBA have attempted — without success — to find training in the evaluation of evidence of torture for the doctors working in detention centres. There is a simple reason for this failure: none of the relevant charities have sufficient confidence in the Agency to be willing to participate. They have seen its behaviour and fear that “training” might be used to justify the rubber stamping of “not tortured” across all forms; this is precisely what happened in other countries when a similar Danish charity agreed to provide training.
Lack of training is no excuse. All doctors have a duty to educate themselves about conditions that they encounter frequently among their patients irrespective of the inactions of their employers. The World Medical Association holds that “the absence of documenting and denouncing acts of torture may be considered as a form of tolerance thereof and of non-assistance to the victims.” And a clinician who cannot document scars and injuries should consider their fitness to practice.
All too often, the problem of the doctors who work in detention centres is not lack of training but a canteen culture, which holds that asylum seekers are, almost by definition, liars.
This perception is reinforced by the governance of healthcare in detention. The Home Office, the paymasters of detention centre doctors, have no known competence in medicine, as evidenced by the still patchy but very substantial improvements that occurred in prison healthcare when it was transferred to the Department of Health.
Doctors who work in detention centres might do well to consider what a Parliamentary committee last week called UKBA’s ‘bunker mentality’, and resist the Border Agency’s often criticised “culture of disbelief”.
In 2006 the Prisons Inspectorate recommended that responsibility for detention centre health care be transferred to the Department of Health. That process will finally commence this month. Perhaps this will effect some of the culture change needed to prevent the harms and waste generated by the present system.
Frank Arnold is a doctor. He frequently examines survivors of torture and is sometimes paid for doing so.
Special illnesses and conditions (including torture claims)
35.—(1) The medical practitioner shall report to the manager on the case of any detained person whose health is likely to be injuriously affected by continued detention or any conditions of detention.
(2) The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
(3) The medical practitioner shall report to the manager on the case of any detained person who he is concerned may have been the victim of torture.
(4) The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
(5) The medical practitioner shall pay special attention to any detained person whose mental condition appears to require it, and make any special arrangements (including counselling arrangements) which appear necessary for his supervision or care.